Opioid Use for Spinal Pain
and Spinal Manipulation as an Alternative
The randomized controlled trial (RCT) is considered the highest
level of evidence to establish causal associations and clinical benefits in clinical research (1, 2). Yet, the medical use of opioids in the Unites States for the treatment of pain has been based on very weak evidence, inflicting enormous harms on the US population (3). A recent (2023) quantification of the magnitude of the harms from opioids states (3):
“The opioid crisis has claimed more than a half-million deaths over the past two decades and is one of the leading causes of injury deaths in the United States.”
Terminology
Opium is a compound made from the poppy plant.
Opiates are compounds that can be purified directly from opium without modification. This includes morphine, codeine, methadone, and heroin.
Opioids are a synthetic form of opium that are made in a chemical lab. Drug companies have created more than 500 different opioid molecules, including:
- OxyContin (oxycodone)
- Percocet (oxycodone)
- Vicodin (hydrocodone)
- Dilaudid(hydromorphone)
- Demerol
- Fentanyl
Both opiate and opioid drugs are known as “narcotics.” Narcotic means sleep-inducing or pain suppressing.
The Numbers
The Centers for Disease Control and Prevention of the United States Government notes (4):
- More than 932,000 Americans have died since 1999 from a drug overdose.
- 75% of these deaths in 2020 involved narcotics (opiates/opioids).
- Overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (like fentanyl), have increased by more than eight times since 1999.
- Over 82% of these deaths involved synthetic opioids, primarily fentanyl.
Side effects of opiates/opioids include insomnia, constipation, jittery nerves, and nausea (5). They also cause life-threatening side effects such as shallow breathing and slowed heart rate, leading to loss of consciousness and death.
In 2017, the United States’ problem with opiates/opioids was quantified in the journal Annals of Internal Medicine in a study titled (6):
Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults
This survey used 51,200 adult subjects. The authors found:
- 8 million (37.8%) U.S. civilian, non-institutionalized adults used prescription opioids.
- 5 million adults misused opiate drugs (12.5%).
- 9 million US adults officially have an opiate use disorder.
- “More than one third of U.S. civilian, non-institutionalized adults reported prescription opioid use in 2015, with substantial numbers reporting misuse and use disorders.”
The authors note that the numbers they present are undoubtedly under representative of the opioid problem because they did not include an assessment of groups that are likely to take and to abuse these drugs, including:
- They did not survey homeless persons who were not living in shelters.
- They did not survey active-duty military personnel.
- They did not survey anyone in jail or other institutions.
The epidemic of deaths from narcotics in the United States began in 1980 when the prestigious New England Journal of Medicine published a letter-to-the-editor by physicians Jane Porter and Hershel Jick, titled (7):
Addiction Rare in Patients Treated with Narcotics
Six years later (1986), pain physicians Russel Portenoy and Kathleen Foley published a small study in the prestigious journal Pain, titled (8):
Chronic Use of Opioid Analgesics in Non-malignant Pain:
Report of 38 Cases
Decades later, in 2018, the first RCT to evaluate opioids for chronic pain was published in the Journal of the American Medical Association, titled (9):
Effect of Opioid vs Non-opioid Medications on Pain-Related Function
in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain:
This study involved 234 subjects. The authors state:
“Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”
“Because of the risk for serious harm without sufficient evidence for benefits, current guidelines discourage opioid prescribing for chronic pain.”
“Studies have found that treatment with long-term opioid therapy is associated with poor pain outcomes, greater functional impairment, and lower return to work rates.”
“Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”
This study was reviewed by the Back Letter, titled (10):
Landmark Trial Punctures the Myth That Opioids
Provide Powerful Relief of Chronic Pain
It is difficult to avoid a sense of profound regret upon hearing the details of the new randomized controlled trial on long-term opioid use by Erin Krebs, MD, and colleagues.
Had this study been conducted and published in 1995, it might have saved 300,000 lives or more—lives lost to opioid overdoses.
Like many major treatment fads for low back pain, the movement to treat chronic noncancer pain with opioids had a flimsy evidence foundation.
Physicians adopted opioids in the early 1990s as a long-term treatment for chronic pain based on the most paltry of evidence—case series and other low-grade evidence.
Many observers blame a 1986 case series by Russell Portenoy, MD, and Kathleen Foley, MD, for jump-starting the use of long-term opioids for chronic, noncancer pain.
They reported 38 cases involving long-term opioid therapy for chronic nonmalignant pain and made the erroneous conclusion that opioids could be used safely and effectively in the long-term treatment of chronic pain.
Emergency physician Chris Johnson, MD, wrote a commentary at CNN.com, describing one such data source:
“As a physician in training, I remember being told that the risk of addiction for patients taking opioids for pain was ‘less than one percent.’ What I was not told was that there was no good science to suggest rates of addiction were really that low.”
Johnson pointed out that this statistic was not based on valid scientific data. It was based on a short letter-to-the editor in the New England Journal of Medicine by two Boston-area medical researchers in 1980.
Many other confounding influences came into play in the genesis of the opioid crisis: unrealistic support for long-term opioids from pain specialists and major pain societies, troubling conflicts of interest between pain specialists and opioid manufacturers, not skeptical attitudes from primary care physicians and their societies, felonious marketing by at least one opioid manufacturer, ...and a lengthy series of other poor decisions by medical systems, regulators, researchers and healthcare providers.
Opioids are perceived as strong pain relievers, but our data showed no benefits of opioid therapy over non-opioid medication therapy for pain.
The data do not support opioids’ reputation as “powerful painkillers.”
This is an impressive study. It is the first clinical trial comparing opioid and non-opioid medications with long-term follow-up. It provides strong evidence that opioids should not be the first line of treatment for chronic musculoskeletal pain.
Opioids are not achieving the benefits for which they are marketed. And everyone is now well aware of the adverse effects of opioids.
In July 2023, a studied published in the journal The Lancet, titled (11):
Opioid Analgesia for Acute Back Pain and Neck Pain (the OPAL Trial):
A Randomised Placebo-controlled Trial
This study was the first RCT looking at opioids for acute spinal pain, and it was placebo controlled. The authors state:
“Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce.”
“The use of opioids for the management of acute low back pain and neck pain is not supported by direct and robust evidence.”
“This study found there was no benefit of an opioid compared with placebo in people receiving guideline care for acute non-specific low back pain or neck pain.”
“Our findings say that not only are opioids not going to benefit individuals with back and neck pain, but they might also cause worse outcomes even after short-term judicious use.”
“Our findings show that even judicious, short-term use of an opioid conferred no benefits in pain reduction and led to a small increase in pain at the medium-term and long-term compared with placebo.”
“There is no evidence that opioids should be prescribed for people with acute non-specific low back pain or neck pain.”
“Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo.”
The authors found that being prescribed an opioid for acute spinal pain actually increased the patient’s pain at both the 26- and 52-week follow-up assessment. In other words, not only did the opioid not work, it actually worsened the patient’s pain in the long term.
••••
In 2018, a study was published in The Journal of Alternative and Complementary Medicine, titled (12):
Association Between Utilization of Chiropractic Services
for Treatment of Low-Back Pain and Use of Prescription Opioids
The authors analyzed the health insurance claims of 6,868 low back pain subjects from New Hampshire. The authors note:
“There is little evidence that opioids improve chronic pain, function, or quality of life.”
“Among U.S. adults prescribed opioids, 59% reported having back pain.”
“Among New Hampshire adults with office visits for non-cancer low-back pain, the adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of services provided by doctors of chiropractic compared with non-recipients.”
“Pain management services provided by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to lower costs and reduced risk of adverse effects.”
“[Chiropractic care] could exert a positive impact on patients with low-back pain by reducing unnecessary care, lowering costs, and improving safety.”
“Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects.”
••••
Also, in 2018, the journal Pain Medicine published a study titled (13):
Opioid Use Among Veterans of Recent Wars
Receiving Veterans Affairs [VA] Chiropractic Care
The authors are from Yale School of Medicine, School of Medicine Boston University, and University of Massachusetts Medical School. The authors state:
“Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients.”
“Chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”
“Our results, along with the previous literature, suggest that expanding access to chiropractic care should be a key policy consideration for the VA, congruent with national initiatives aimed to increase the use of evidence-based nonpharmacological treatments for chronic musculoskeletal pain.”
••••
In 2019, a study was published in the journal BMJ Open titled (14):
Observational Retrospective Study of the Initial Healthcare Provider
for New-onset Low Back Pain with Early and Long-term Opioid Use
The authors examined the association of initial conservative therapy provider treatment (chiropractors, acupuncturists, physical therapists) on opioid use in a national sample (216,504) of individuals with a new-onset low back pain (LBP). The most frequent initial conservative provider seen was a chiropractor. The authors note:
“Comparisons of the treatment patterns of primary care physicians and conservative therapists (defined as chiropractors, physical therapists, acupuncturists) suggest that the use of conservative therapies for LBP may decrease the likelihood of opioid use.”
“For early opioid use, patients initially visiting chiropractors had 90% decreased odds.”
“Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids.”
••••
In 2020, a study was published in the journal Pain Medicine titled (15):
Association Between Chiropractic Use and
Opioid Receipt Among Patients with Spinal Pain
The authors are from Yale School of Medicine. The authors note:
“Chiropractors predominantly manage spinal conditions, with back conditions being the most common reason to seek chiropractic care.”
“The main finding of the review was that all included studies demonstrated a negative association between use of chiropractic care and opioid prescription receipt.”
“Chiropractic users had 64% lower odds of receiving an opioid prescription than nonusers.”
••••
In 2020, a study was published in the journal Pain Medicine, titled (16):
Impact of Chiropractic Care on Use of Prescription Opioids
in Patients with Spinal Pain
The objective of this study was to evaluate the impact of chiropractic utilization upon use of prescription opioids among 101,221 patients with spinal pain. The authors note:
“Among patients with spinal pain disorders, for recipients of chiropractic care, the risk of filling a prescription for an opioid analgesic over a six-year period was reduced by half, as compared with non-recipients.”
“[There is] accumulating evidence for increased utilization of chiropractic services as an upstream strategy for reducing dependence upon prescription opioid medications.”
••••
In 2022, a study was published in the Journal of Chiropractic Medicine, titled (17):
Associations Between Early Chiropractic Care and Physical Therapy
on Subsequent Opioid Use Among Persons with Low Back Pain in Arkansas
The objective of this study was to estimate the association between early use of physical therapy (PT) or chiropractic care and incident opioid use and long-term opioid use in individuals with low back pain. Study subjects included 40,929 patients with LBP without prior opioid use. The authors note:
“Low back pain (LBP) is the most common noncancer pain complaint for which opioids are prescribed.”
“Nearly 80% of opioid users take their pain medication long-term.”
“The use of chiropractic care within 30 days of LBP diagnosis was associated with diminished use of opioids in the short-term and, in particular, the long term, in which the risk of long-term opioid use was almost cut in half.”
“Chiropractic care was associated with substantial reduction in likelihood of any opioid use and of long-term opioid use, and no association was observed with PT.”
“Utilization of chiropractic care was associated with substantial reduction in likelihood of any opioid use and long-term opioid use.”
••••
In 2022, a study was published in the Journal of the Canadian Chiropractic Association, titled (18):
A Retrospective Analysis of Pain Changes and Opioid use Patterns
Temporally Associated with a Course of Chiropractic Care
at a Publicly Funded Inner-City Facility
The authors note:
“Non-pharmacologic treatment, including chiropractic care, is now recommended instead of opioid prescriptions as the initial management of chronic spine pain by clinical practice guidelines.”
“Spinal manipulative therapy has been demonstrated to be a cost-effective treatment option for the management of back pain and results in high reported levels of patient satisfaction.”
“Pain and opioid use significantly decreased concomitant with a course of chiropractic care.”
“92% of chiropractic patients using opioids were able to be discharged without further referral for their musculoskeletal spine pain following a course of chiropractic care.”
“A potential solution to consider for patients with chronic spinal pain is a course of chiropractic care, a non-pharmacological healthcare intervention.”
“The results of the present study found a statistically and clinically significant pain reduction concomitant with publicly funded chiropractic management in a low-income population who utilized opioids.”
••••
In 2025, a study was published in the journal Health Science Reports, titled (19):
Association Between Spinal Manipulative Therapy for Low Back Pain
With or Without Sciatica and Opioid Use Disorder:
A Retrospective Cohort Study
The authors tested the hypothesis that opioid?naïve adults receiving spinal manipulative therapy (SMT) for LBP are less likely to develop opioid use disorder (OUD) compared to matched controls prescribed ibuprofen over 2 years follow?up. Both the SMT cohort and the ibuprofen cohort had 24,993 patients.
The authors state:
“Opioids are narcotic analgesic medications commonly prescribed for LBP, despite their known risks (e.g., constipation, addiction, and overdose) and limited evidence supporting their efficacy.”
“Opioid use disorder (OUD) is a complex disease characterized by chronic use of opioids leading to substantial distress or impairment in daily life.”
“OUD is also associated with economic and societal costs, lost work productivity, increased healthcare use, and harms to family cohesion.”
“Spinal manipulative therapy (SMT) is a common treatment for LBP often used by chiropractors in the US.”
“Patients receiving spinal manipulative therapy (SMT) for low back pain (LBP) are less likely to be prescribed opioids.”
“Studies have found that those visiting a chiropractor and/or receiving SMT are less likely to be prescribed opioids.”
“SMT recipients were less likely to be diagnosed with opioid?related disorders, have long?term opioid use, or be prescribed an opioid.”
“The reduction in opioid prescriptions among SMT recipients corroborates previous studies that observed similar findings.”
“Adults receiving SMT for LBP with or without sciatica had a significantly lower risk of developing OUD over a 2?year follow?up compared to those prescribed ibuprofen.”
“These findings align with prior research associating SMT with reduced opioid prescription and related harms.”
“[These] study findings support the hypothesis that adults receiving SMT for LBP with or without sciatica have a lower risk of developing OUD compared to those receiving ibuprofen.”
In this study, the SMT cohort had a significantly lower incidence and risk of OUD compared to the ibuprofen cohort, by approximately 600%. The authors made these recommendations:
“Payers, including Medicare and Medicaid, such as in this current study, could consider real?world data to support expanding coverage and reimbursement for nonpharmacologic treatments like SMT, which often faces stricter condition requirements, visit limits, and/or higher out?of?pocket costs compared to other conservative care options.”
“Such changes could ultimately mitigate OUD risk and downstream care cascades in LBP management.”
“The present findings support existing clinical guidelines that recommend SMT as a nonpharmacological intervention for LBP with or without sciatica in adults.”
“[These findings] corroborate previous work, which collectively suggests that access to SMT as a first-line treatment for LBP could contribute to opioid?sparing efforts and reductions in opioid?related sequelae.”
“To prioritize non-pharmacologic care in LBP management and potentially mitigate OUD risk in opioid?naïve patients with new LBP, primary care providers and pain management specialists could consider early care pathways to chiropractors for SMT.”
“These findings corroborate guidelines recommending first?line SMT for LBP.”
“Our findings, suggesting a reduced risk of OUD associated with SMT for LBP, may have implications for health policy.”
Collectively, these presented studies continue to support the use of chiropractic spinal adjustments for the management of spine pain syndromes. They especially show that chiropractic spinal care is much preferred over opioid drugs.
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- Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CWC; Opioid Analgesia for Acute Back Pain and Neck Pain (the OPAL Trial): A Randomised Placebo-controlled Trial; Lancet; July 22, 2023; Vol. 402; No. 1; pp. 304-312.
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- Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC and 11 more; Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care; Pain Medicine; September 1, 2018; Vol. 19; Supplemental; pp. S54–S60.
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- Whedon JM, Toler AWJ, Kazal LA, Bezdjian S, Goehl JM, Greenstein J; Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain; Pain Medicine; December 25, 2020; Vol. 21; No. 12; pp. 3567-3573.
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- Passmore S, Malone Q, Manansala C, Ferbers S, Toth EA, Olin GM; A Retrospective Analysis of Pain Changes and Opioid use Patterns Temporally Associated with a Course of Chiropractic Care at a Publicly Funded Inner-City Facility; Journal of the Canadian Chiropractic Association; 2022; Vol. 66; No. 2; pp. 107-117.
- Trager RJ, Cupler ZA, Gliedt JA, Fische RA, Srinivasan R, Hannah Thorfinnson H; Association Between Spinal Manipulative Therapy for Low Back Pain With or Without Sciatica and Opioid Use Disorder: A Retrospective Cohort Study; Health Science Reports; September 19, 2025; Vol. 8; No. 9; Article e71267.
“Authored by Dan Murphy, D.C. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”